Christian Waldherr

Intra-and Retroperitoneal Irrigation Liquid After Arthroscopy of the Hip Joint

The case of intra- and retroperitoneal irrigation solution after hip arthroscopy of a 15-year-old girl is presented. She underwent hip arthroscopy for intra-articular adhesiolysis after previous surgical dislocation of the hip for the treatment of femoroacetabular impingement. Arthroscopy was performed in the lateral decubitus position without traction to debride the peripheral joint compartment. The irrigation pressure was set at 40 mm Hg. There were no intraoperative complications. By the end of surgery, the anesthesiologist reported a drop in the patients body temperature from 36.3 degrees to 34.5 degrees C. Postoperatively, she complained about abdominal swelling and discomfort. Abdominal sonography revealed approximately 2 to 3 L of intra- and retroperitoneal liquid, which was considered to be irrigation fluid. The irrigation fluid was absorbed within 16 hours without further treatment. The only possible way the irrigation fluid could have flown was a retroperitoneal course along the iliopsoas muscle and the iliac vessels with intraperitoneal perforation along their course. We observed at arthroscopies that irrigation pressure incidentally can rise to 140 mm Hg when leaking of fluid through the portals occurs. Intra-abdominal fluid is a potentially devastating complication. A sudden drop of body temperature has to raise suspicion for intra-abdominal leaking of irrigation fluid.

Value of One-View Breast Tomosynthesis Versus Two-View Mammography in Diagnostic Workup of Women With Clinical Signs and Symptoms and in Women Recalled From Screening

OBJECTIVE The purpose of this study is to compare the diagnostic value of one-view digital breast tomosynthesis versus two-view full-field digital mammography (FFDM) alone, and versus a combined reading of both modalities. MATERIALS AND METHODS The datasets of one-view digital breast tomosynthesis and two-view FFDM of abnormal mammograms in 144 consecutive women admitted for diagnostic workup with clinical signs and symptoms (n = 78) or recalled from screening (n = 66) were read alone and in a combined setting. The malignant or benign nature of the lesions was established by histologic analysis of biopsied lesions or by 12-16-month follow-up. RESULTS Eighty-six of the 144 patients were found to have breast cancer. The BI-RADS categories for one-view digital breast tomosynthesis were significantly better than those for two-view FFDM (p < 0.001) and were equal to those of the combined reading in both women admitted for diagnostic workup and women recalled from screening. The sensitivity and negative predictive values of digital breast tomosynthesis were superior to those of FFDM in fatty and dense breasts overall and in women admitted for diagnostic workup and in women recalled from screening. Only 11% of digital breast tomosynthesis examinations required additional imaging, compared with 23% of FFDMs. CONCLUSION In patients with abnormal mammograms, one-view digital breast tomosynthesis had better sensitivity and negative predictive value than did FFDM in patients with fatty and dense breasts. They also suggest that digital breast tomosynthesis would likely increase the predictive values if incorporated in routine screening.

Interventional Management of Hypervascular Osseous Metastasis: Role of Embolotherapy Before Orthopedic Tumor Resection and Bone Stabilization

OBJECTIVE The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization. MATERIALS AND METHODS Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries. RESULTS In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient. CONCLUSION The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization.

Indications for Three-dimensional (3D)/Digital Breast Tomosynthesis (DBT)

the patient was born in 1965; she presented with significant palpable laterocranial mastopathy on both sides.

Synthetic 2D Mammography with 3D Tomosynthesis as Screening Tool: Early Detection and Reduced Recall

Two-dimensionlal (2D) mammography screening programs reduce breast cancer mortality substantially, but they do not depict all cancers early enough to result in a cure. Thus, to detect cancers earlier, the aim has to be to increase the sensitivity and specificity of the diagnostic methods used (Coldman et al. 2007, 2014; Heywang-Kobrunner et al. 2011; The Swedish Organized Screening Evaluation Group 2006; Jonsson et al. 2007; Allgood et al. 2008; Parvinen et al. 2006; Schopper and deWolf 2009; Gabe et al. 2007; Roder et al. 2008; Kopans 2014b). Tomosynthesis (3D) fulfills these criteria and will, in the end, replace standard 2D digital mammography for breast cancer screening (Kopans 2014a). Many of the arguments against 2D mammography screening raised through recent years are based on faulty science (Heywang-Kobrunner et al. 2011; Kopans 2014b). Indeed, there are true disadvantages of 2D mammography screening, such as radiation risks, the risk of a false alarm, interval cancers, and—to a certain point—overdiagnosis (Heywang-Kobrunner et al. 2011). Many of these disadvantages will be markedly reduced due to the emerging widespread use of tomosynthesis. 2D mammography is associated with a small amount of radiation. But the average glandular dose is low, calculated as 4 mGy per breast. The individual dose may differ depending on breast size and compression (Heywang-Kobrunner et al. 2011). According to the literature, tomosynthesis with synthetic 2D views reduces the breast dose by approximately half, which has substantial implications for the future of population screening programs (Svahn et al. 2015). Like every medical test, screening 2D mammography may detect abnormalities that require further evaluation, but will eventually turn out to be benign. Psychologically, such a false-positive alarm causes distress. Meanwhile, many studies have shown that the recall rate of tomosynthesis (2D + 3D) is significantly lower than that in the 2D mammography-alone group, even if the combination 2D + 3D group has additional risk factors (recall rate for 2D, 11.5 %; in the combination 2D + 3D group, 4.2 %) (Destounis et al. 2014). Interval cancers represent a limitation of screening and not a side effect. Screening does not allow us to recognize these cancers at a preclinical stage. They exist, but are 2D mammographically occult and become clinically detectable during the screening interval (Heywang-Kobrunner et al. 2011). Meanwhile, many studies have shown that the use of 2D + 3D in a screening environment results in a significantly higher cancer detection rate and enables the detection of more invasive cancers (Skaane et al. 2013, 2014; Ciatto et al. 2013). It can be accepted that these cancers were occult on the regular 2D mammography screening and later found at a more advanced stage. Improved possibilities of treatment are an important advantage of early detection. It is well known that early detection leads to a reduced number of mastectomies, better cosmetic results in cases of breast conservation, reduced adjuvant chemotherapy, and increased replacement of axillary dissection by sentinel node biopsy (Heywang-Kobrunner et al. 2011). Overdiagnosis of breast cancer in a screening program describes the fact that, in a screened population, more breast cancers are detected than in a comparable unscreened population of the same age and composition. Some of the additional cancers that are detected in the screening group would never have become apparent without screening, and their detection does not contribute to mortality reduction (Heywang-Kobrunner et al. 2011). A quite realistic and very sophisticated calculation was presented by Duffy et al. in 2010 (Duffy et al. 2010). They concluded that the lifesaving effects of mammography screening exceeded the potential harm of overdiagnosis by a factor of 2–2.5. Since some ductal carcinoma in situ (DCIS; even though being a precursor) may not develop into invasive breast cancer during the remaining lifespan of a woman, DCIS must be considered a potential and real source of overdiagnosis or, rather, overtreatment and thus requires special attention. Someone could suggest that the use of 3D would lead to more overdiagnosis/overtreatment and thus in the end to more and more costs. But the contrary is demonstrated by Bonafede et al., who have shown clinical and economic favorability of 3D for breast cancer screening among commercially insured women in the United States (US) (Bonafede et al. 2015).

Benign Changes (Cysts, Fibroadenomas, Papillomas, Infection…): BI-RADS

The patient was a 56-year-old female. Previous bilateral breast reduction. Routine screening mammography and tomosynthesis (3D), 17.6.2013. Tomosynthesis-guided vacuum-assisted biopsy (T-VAB) (27.06.2013).

BI-RADS Reporting for Breast Tomosynthesis (3D-Mammography)

The Breast Imaging Reporting and Data System (BI-RADS) was developed in 1993 by the American College of Radiology (ACR) to standardize mammographic reporting, to improve communication, to reduce confusion regarding mammographic findings, to aid research, and to facilitate outcome monitoring. It contains a lexicon of standardized terminology (descriptors) for mammography, breast US, and MRI, as well as chapters on Report Organization and Guidance Chapters for use in daily practice. Because breast tomosynthesis (three dimensional, or 3D, mammography) only unmasks and highlights the morphology of mammographic findings, the descriptors of the BI-RADS lexicon can be easily adopted for use. The standard reporting includes the description of the breast composition (ACR a-d, previously ACR 1-4) as well as the description of any significant finding using standardized morphological descriptors. These descriptors eventually guide to a final assessment category, a measure of how likely is malignancy (BI-RADS categories 0-6).

Introduction to Tomosynthesis

Mammography is X-ray imaging of the breast. The technique works because different components of the breast absorb X-rays in different amounts, generating an image in which fat, fibrous, and glandular tissue; soft tissue lesions; and calcifications can be identified. Fibroglandular tissue and soft tissue lesions have almost identical X-ray absorption properties, which can make identifying small cancers challenging when using mammography. Unless a lesion is located in a region that is surrounded by fat, its visibility is reduced because of the shadows of fibroglandular structures overlying the cancer. These interfering structures are sometimes referred to as structure noise or anatomical noise. In denser breasts, there are more structures that interfere with seeing a cancer, and the clinical performance of mammography decreases with increasing breast density (Pisano et al. 2005). The sensitivity, or ability to detect cancer, is lower in extremely dense breasts compared with breasts consisting mainly of fat.